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Based on observation and interview, the hospital was found not in compliance with the Condition of Participation related to the Physical Environment (42 CFR 482.41). Findings include:

The hospital failed to maintain the hospital in a safe and sanitary manner. Please refer to A0701 for additional information.

The hospital was found not in compliance with the Condition of Participation related to the Physical Environment (42 CFR 482.41) as evidenced by deficiencies issued as a result of a Life Safety Code Inspection.

Please refer to Life Safety Code Inspection tags: K29, K38, K52, K56, and K62 for additional information.

Based on observation, interview, and record review, the hospital was not found to be in compliance with the Condition of Participation related to Infection Control (42 CFR 482.42). The hospital failed to provide a sanitary environment to avoid sources and transmission of infections and communicable diseases.

Refer to findings at A 749. The facility did not implement their appropriate infection control policy. Precautions were not followed related to glove changing and handwashing, administering medication, cleaning of equipment, performing cares such as emptying catheter or ileostomy bags, incontinence care, performing blood glucose checks, when going from patient to patient, and when transferring soiled laundry.

Based on interview and record review, the hospital failed to respond in writing to the patient regarding the results of the grievance process for 9 of 12 patient grievances filed (20, 21, 24, 32, 26, 27, 25, 29, and 28) from October through December 2009. Findings include:

Patient grievances that could not be quickly resolved did not include a written notice to the complainant regarding the hospital's determination regarding the grievance.

P20 filed a grievance on 10/19/09 regarding the lack of repositioning in a timely manner. Although the complaint was investigated, there was no written response to the patient.

P21 filed a grievance on 10/5/09 regarding the appropriate application of a back brace and disrespectful communication by staff. The grievance was investigated with appropriate actions taken, but no written response was given to the patient.

P24 filed a grievance on 11/5/09 regarding staff not listening to patient concerns and inability to answer patient and family's questions. Although a family conference was conducted to address the matter, there was no written communication regarding follow-up on the issues.

P32 filed a grievance on 11/6/09 regarding a particular nursing assistant's attitude and care provided. The grievance was investigated and interventions put into place, however, there was no written response provided to the family or patient.

P26 filed a grievance 12/16/09 regarding a bed pan left on the patient's bed. No written response in response to the problem was sent to the patient.

P27 filed a compliant on 12/14/09 in relation to poor quality of care provided by a nurse. Although properly investigated, the hospital failed to respond to the patient in writing.

P25 filed a grievance on 12/8/09 alleging rude staff behavior toward the patient. The facility did not provide a written response to either family or patient.

P29 filed a grievance 12/8/09 regarding a room transfer from the Intensive Care Unit to a regular hospital room, and the patient was not made aware of this possibility at time of admission. No written response was provided.

P28 filed a grievance on 12/31/09 alleging rude nursing staff and not providing necessary cares. The matter was investigated, but the facility failed to respond to the patient in witting.

An interview was conducted with the quality coordinator on 1/13/10, at 2:15 p.m. The coordinator stated she did not realize that after investigations were completed, written responses were required.

The hospital policy titled Patient Complaint/Grievance Resolution #LD301 stipulated, "All grievances will be responded to in writing within an average of seven (7) days."

Based on interview and record review, the hospital failed to report a death potentially associated with the use of restraints within the required time frame for 1 of 2 patients (9) whose death records were reviewed. Findings include:

P9 required the use of non-behavioral restraints due to agitated and confused behavior of removing medically necessary tubing. The medical restraints were initiated on 1/3/10 at 10:00 a.m. On 1/11/10, the patient's condition declined and the patient went into a comatose state. The family elected for comfort care only, and it was documented the restraints were discontinued at 11:00 a.m. The patient expired later that day. The facility, however, did not notify the Centers for Medicare and Medicaid Services (CMS) until 1/14/10.

The hospital policy regarding restraints was reviewed (revised 2008). In accordance with CMS regulations, the policy stipulated, "Each death referenced in this policy must be reported to CMS by telephone no later than the close of the business the next business day following knowledge of the patient's deaths."

The quality coordinator was interviewed on 1/14/10, at 8:45 a.m. She explained that she notified the corporate office of the death on 1/11/10, and the office was to have notified CMS. On 1/14/10, at 10:50 a.m. the hospital staff informed the surveyor the reporting of the death was "missed," but had since been reported to CMS on 1/14/10 at 10:38 a.m. during the survey.

Based on observation, interview and record review the hospital failed to ensure medical record entires included the time a physician order was written for 6 of 30 patient records (4, 7, 5, 2, 14, and 16) reviewed. Findings include:

The time was not specified consistently on physicians' orders for patients as required.

P4's physician orders written by Physician-C on 1/11/10, and the orders did not indicate a time:
1. Transfer patient to Medical Intensive Care Unit (MICU)
2. Give Diltiazem 10 mg intervenously (IV) times one (heart medication)
3. Start Diltiazem drip at 5 mg a hour
4. IVF ( Intervenous fluid) bolus 500 cc times one
5. Check HGB (Hemoglobin)
6. Hold Lasix and Aldactone for now (both diuretics)
7. Repeat IVF 500 ml times one
The following orders were also ordered on 1/11/10 for P4 without a time specified by physician-A:
1. Serum TSH this a.m.
2. Mg (Magnesium) rider 2 grams IV times one over 2 hours

P7's physician's orders written by Physician-E on 1/11/10 did not specify a time the orders were written:
1. Change Tracheostomy (trach) to #7 Bivona at bedtime (type of tubing)
2. Try capping as tolerated during day after trach changed
3. Lasix 20 mg per nasal gastric tube or by mouth every morning
4. 1/12/10 a.m. labs--BMP,BNR (laboratory tests)

P5's had a physician's order on 1/7/10 to change Prednisone to 25 mg via feeding tube daily, but the time was not indicated.

P2 had an order dated 1/12/10 written by Physician-D, for a gradual dose reduction of the medication Klonopin (anti-convulsant commonly used for anxiety), however, there was no time indicated on the order.


13611

P14 had a physician's order written by Physician-A and dated 1/11/10 for receive one bottle of Gastrografin (radiology dye) for verification of nasogastric tube position, as well as a repeat abdominal X-ray to verify the position of the nasogastric tube. However, the physician did not indicate the time the order was written. Physician-D wrote an order on 1/11/10 to increase the patient's scheduled dose of Seroquel (antipsychotic medication) to 12.5 milligrams (mg) per feeding tube at 9:00 a.m. 1:00 p.m. and 5:00 p.m. and 100 mg at 9:00 p.m. However, the physician did not indicate a time the order was written.

P16 had a physicians's order written on 12/29/09 by Physician-D to increase the patient's dose of Seroquel to 50 mg per feeding tube three times a day, 200 mg at bedtime, and 50 mg per feeding tube every four hours as needed for agitation. The order also directed staff to hold the Seroquel and Haldol (antipsychotic medication) should cardiac irregularity occur. Another physician order was written on 1/8/10 to increase of Cogentin (anti-Parkinsonian drug) to 1 mg per feeding tube three times a day. On 1/13/10 the physician ordered the Cogentin discontinued. The physician did not specify the times the orders were written.

The health unit coordinator (HUC-A) was interviewed on 1/14/10, at 9:25 a.m. She reviewed the physician orders and verified the times the orders were written were not specified by the physicians.

Based on interview and record review, the hospital failed to ensure physician's orders were followed for 1 of 30 patients (P11) whose medical records were reviewed. Findings include:

P11's medical record revealed a physician order not carried out by the hospital staff as ordered.

The order dated 12/23/09 requested the hospital to obtain a "C. difficile assay" laboratory test performed on stool to determine if the patient had a Clostridium difficile (C. difficile) infection, which caused diarrhea.

P11 had an ileostomy (artificial anus) and was observed to have loose yellow, tan stool in the ileostomy bag on 1/12/10. Review of the 24-hour report on 1/12/10 record indicated the patient had a moderate amount of tan, liquid stool. Nurses notes dated 1/12/10 indicated the patient was having large amounts of stool and flatus. It also indicated the patient had contact isolation precautions because of the presence of Vancomycin-resistant enterococci (VRE) and Methicillin-resistant Staphylococcus aureus (MRSA). These were all infections that did not responsed well to antibiotics. The record indicated the patient had a negative test for C. difficile upon admission on 11/18/09.

An interview was conducted with a registered nurse (RN-D) and P11's record was reviewed on 1/13/10 at 9:45 a.m. The RN confirmed the C. difficile assay was not completed as ordered by the physician on 12/23/09. She planned to inform the patient's physician so appropriate follow-up could be initialed, if needed. She said she would also reported it as a "missed order."

The infection control nurse (Nurse-A) was interviewed on 1/13/10 at 2:00 p.m. The nurse reported that after the physician was informed of the missed laboratory testing, the physician chose not to proceed with the C. difficile testing. She explained that although laboratory results were not performed to confirm the presence of C. difficile, the physician treated P11 as if C. difficile were present. The nurse stated she did not know whether the patient was positive for the C. difficile infection.

Based upon interview and record review, the hospital did not ensure drug administration errors were immediately reported to the physician for 2 of 4 patient medication errors reviewed (30 and 31). Findings include:

A Medication Variance Report dated 9/16/09 indicated a medication error for P30 occurred the same date. The report indicated the physician had ordered Simethicone 80 milligrams (mg) (to treat gastric bloating) four times a day to be administered via feeding tube. The report indicated the pharmacy had dispensed Simvastatin 80 mg (medication to lower cholesterol ) to be administered four times a day via feeding tube. The report indicated the patient had received one dose of the wrong medication the morning of 9/16/09. The report indicated the error had resulted in no harm to the patient.

Nursing notes were reviewed from 9/15 to 9/20/09. There was no notation to indicate the physician was immediately notified of the medication error.

A Medication Variance Report, dated 10/6/09, indicated a medication error occurred on 10/1/09. The report indicated a physician had ordered Sinemet 25/100 (for Parkinson's disease). The report indicated a pharmacist had dispensed Sinemet 25/250 and the the patient had received the wrong dose for five days. The report also indicated the patient did not experience harm related to receiving the wrong medication dosage.

Nursing notes were reviewed from 9/30 through 10/2/09. No notations were made to show the physician was immediately notified of the medication error.

The chief operating officer and chief pharmacist were interviewed on 1/14/10 at approximately 1:45 p.m. They stated physicians were notified of medication errors and nurses documented in the nursing notes. At 4:45 p.m., the chief pharmacist stated the physicians were not immediately notified of the errors for P30 and P31.

Based on record review and staff interview, the hospital failed to ensure a qualified radiologist supervised radiological services. Findings include:

A review of the hospital's organization chart revealed the radiology technician was under the direct supervision of the chief operating officer (COO)/registered nurse (RN), not a radiologist, as required.

The radiology technician was interviewed on 1/13/10, at 8:15 a.m. and confirmed the COO was the technician's supervisor, and there was no supervision by a staff radiologist or consulting radiologist.

The COO was interviewed on 1/14/10, at 4:30 p.m. The COO explained that the radiology technician did not perform any ionizing radiology services, therefore was not supervised by a radiologist. However, X-rays were being performed at the patients' bedside.

Based on observation and staff interview the facility failed to maintain the facility in a safe and sanitary manner. Findings include:

A tour of the facility was conducted on 1/12/10, at 1:45 p.m. with the director of plant operations. During the tour the following areas were noted to need maintenance and/or housekeeping services:

Three of three nursing stations on second floor had missing and chipped veneer in multiple areas.

Numerous radiators had multiple gray dirt stains in rooms 212, 224, 225, 227, 228, 233, 240, 242, 254, 256, 260, 261, the two north day room, physical therapy, and radiology.

Room 249 had a very dirty wheel chair with built-up of dust on all metal parts and dried liquid spills.

In the special care unit, rooms 2, 3, 4, 5, 6, and 7 had intake ceiling vents with brown stains.

The two central water fountain was dusty and a small white beaded material on the surface.

The two north patient day lounge had a dirty microwave with dried food spills. The crash cart on two south had a thick layer of dust.

The director of plant operations confirmed the findings.

Based on observation, interview, and record review, the hospital failed to ensure infection control practices were followed during patient care observations for 4 of 5 patients (5, 10, 11, and 12) whose cares were observed, and to promote a sanitary environment related the cleaning of equipment and transferring of linens. Findings include:

Appropriate infection control precautions were not followed related to glove changing and handwashing, administering medication, cleaning of equipment, performing cares such as emptying catheter or ileostomy bags, incontinence care, performing blood glucose checks, when going from patient to patient, when transferring soiled laundry, etc.

P5 was not provided appropriate infection control services to prevent the spread of infection.
The patient's diagnoses included respiratory failure, ventilator dependency, and Methicillin-Resistant Staphylococcus Aureus (MRSA) in the nares and sputum. Upon entering P5's room contact precautions were noted. The surveyor asked the nurse why the patient was on the precautions, and the registered nurse (RN-A) said she didn't know why, but "Everyone here has some issues with infections." RN-A then donned a gown and gloves prior to entering the room. After administering P5's medications, RN-A set up the patient's breakfast tray. The plastic dome was removed from the plate and placed on the patient's bed. The RN then left the room and the food cover remained on the bed.

The infection control nurse was interviewed on 1/13/10, at approximately 1:00 p.m. The nurse informed the surveyor it was "unacceptable" for staff not to be knowledgeable as to a patient status related to infection. The nurse explained P5's kardex (a quick patient information reference), medical record, and a posting behind the nursing station all contained information regarding P5's MRSA status. The nurse also indicated staff should have not placed the plate dome on the P5's bed.


12831

P10 was not provided appropriate infection control services to prevent the spread of infection. Contact precautions were in place for P10 (staff needed to wear gloves and a gown when in the room with the patient to decrease the spread of infections). P10's diagnoses included respiratory failure with a goal of ventilator/tracheostomy weaning, as well as treatment or recurrent Enterococcal bacteremia and rehabilitation. A sputum culture dated 1/7/10 indicated the resident had heavy growth of Gram Negative Bacilli and heavy growth of Enterobacter Cloacae which could cause significant infections. Antibiotics which could be used were suggested. The 24-hour patient record dated 1/12/10 indicated the patient had MRSA and Clostridium difficile (C. difficile).

RN-B was observed on 1/12/10, at 8:45 a.m. to don a gown and gloves prior to entering P10's room. The RN brought a medication administration record (MAR) form in the patient's room and set it on the bedside table. The RN touched patient and hospital gown while checking a PICC (peripherally inserted central catheter) line. The RN then moved the MAR form to the fold-down lock box table, which was soiled with what appeared to be dried blood. The substance was splatters of a thick, dark red material in an area approximately of 3/4 by 1 1/2 inch. The patient's medications were then set on the table and prepared for administration via the patient's feeding tube. The RN then picked up the pill crusher and set it on the MAR paper. As she was setting up the patient's medications at the bedside table, the RN placed her gloved hand into her pocket to check recorded vital signs, thus further contaminating the pocket and the paper. While wearing the same gloves, the RN then left the room to retrieve a forgotten item, which required touching the door handle. After the medications were administered, the RN removed her gloves and washed her hands. However, she then touched the contaminated door handle and returned the contaminated MAR form to the book which other staff would use.
On 1/12/10, at approximately 9:30 a.m. RN-B was interviewed. She stated she did not know whether the hospital had a policy or procedure on how to prevent the MAR forms from becoming contaminated when needed in patient rooms for those on contact precautions. She said she understood how she contaminated the form during the medication administration process. She explained that some of the nurses took the entire MAR book into the patients' rooms and some took the pages they needed. The RN also confirmed she contaminated her gloves and did not change them appropriately, nor did she clean the splatters from the table prior to setting up the patient's medications.

P11 was not provided appropriate infection control services to prevent the spread of infection.
Contact precautions were in place for P11, who according to a history and physical dated 11/18/09, had diagnoses including recurrent deep decubitus ulcers, hepatic infection, ileostomy with high out put, MRSA in the urine, and diabetes.

The RN-C was observed on 1/12/10, at 8:20 a.m. to don a hospital gown and gloves prior to entering P11's room. The RN brought the MAR book in the patient's room and set the book on the bedside table. The table was not clean, and had a spilled sticky pink substance approximately 1.5 inches by 3.5 inches on the surface. The MAR was placed on top of the sticky substance. The RN-C then touched the patient and the patient's hospital gown while listening to heart, lungs, abdomen sounds, and checking vital signs. RN-C then set up and administered the patient their medications with out changing gloves. The RN paged through the MAR to check the orders and to document the medications as given. While wearing the same gloves, the RN then flushed the patient's PICC line. The gloves were then removed and without cleaning the MAR, the RN left the room carrying the MAR. The RN then returned to the patient's bedside, and placed the MAR on the soiled bedside table. The patient's urine bag was emptied and the RN touched the MAR without changing her gloves and washing her hands. The RN then removed the gloves and washed her hands, and then carried the soiled MAR out of the room without cleaning it.
The RN-C donned gloves and a hospital gown on 1/12/10 at 11:37 a.m. After doing so, another patient in the day room outside P11's room requested assistance to the bathroom. The RN then wheeled the patient to his room and handed him the urinal. Without changing her gloves and washing her hands, she then picked up the blood glucose case and went into P11's room. The glucose machine case was placed on the fold down lock table. The RN opened the case and used the glucometer to test the patient's blood. After removing the bloody test strip from the glucometer, she returned the glucometer to it's case. The RN did not clean the glucometer or the case after its use. The RN then emptied P11's ileostomy bag (a bag used to catch stool). Without changing gloves and washing her hands, she closed the lid on the glucometer case. She then removed the soiled gloves and used an alcohol-based hand sanitizer. The RN picked up the glucometer case with her un-gloved hands in the same contaminated place where she closed it.
On 1/12/10, at approximately 11:45 a.m. RN-C was interviewed, and confirmed she did not use proper infection control procedures when caring for P11. When asked if the hospital had a policy or procedure for cleaning glucometers and MARs, the RN said she did not know.
The infection control nurse was interviewed on 1/13/10, at approximately 2:00 p.m. The nurse confirmed the above practices were infection control breeches. She indicated they did have a policy for using the MAR when in a patient's room. Staff was to wear clean gloves when handling the MAR, and then wash off the MAR when removing it from the patient's room. She also stated the glucose machine and case should have been cleaned prior to removing from the patient's room.


13611

P12 was not provided appropriate infection control services to prevent the spread of infection. P12 had diagnoses including a non-healing foot ulcer and the presence of C. difficile in his stool. Staff was to use contact precautions, including gowning and gloving while caring for the patient.

P12 was observed on 1/13/10 at 9:15 a.m. as a physical therapy assistant (PTA-1) and a rehabilitation aide (RA-1) placed a protective gown over the patient's clothing and gloves on his hands. The staff then assisted the patient to ambulate in the hallway. When PTA assisted the patient back into his wheelchair, the patient's incontinent product slid down to above his knees. While still in the hallway, the PTA removed the incontinent product which had urine and stool present, and with gloved hands, placed the soiled product in a wastebasket in the patient's room. The PTA did not change the gloves and wash hands before returning to the patient, who remained in the hallway. The patient was then wheeled back to his room and was assisted to lie down. The transfer belt was also removed, monitor leads attached to the patient's chest, the side rail was pulled up, and the transfer belt hung on the wall, all while wearing the same gloves. The PTA then removed the gown and gloves and cleaned her hands with an alcohol-based product and washed her hands.

The infection control nurse was interviewed on 1/13/10 at approximately 10:40 a.m. She stated the PTA-1 should have removed the gloves after placing the incontinence product in the wastebasket, washed her hands and applied clean gloves.

LAUNDRY
Laundry was not covered during transport on the nursing units. A staff person was observed pushing two tall carts of uncovered clean laundry past the 2 South nursing unit on 1/13/10 at 8:08 a.m. At 8:12 a.m., uncovered soiled laundry carts were pushed past the nursing units.

A review of the hospital's policy Linen Distribution, Collection, and Storage (dated 5/2/08) indicated clean linen was to be covered at all times.

The director of plant operations was interviewed on 1/13/10, at 2:00 p.m. The director verified the laundry should have been covered during transport outside of the laundry department.

ENVIRONMENT
The microwave ovens and the toaster in the dining room for use by patients, visitors, and staff were very soiled.

On 1/12/10, at 9:45 a.m. two microwave ovens in the dining room were observed to have a heavy build-up of dried food debris present. The toaster had a large amount of crumbs present in and around the toaster. The following day at 10:50 a.m., and again on 1/14/10, at 10:45 a.m. the microwave ovens and the toaster continued to have a large amount of dried food debris present.

The director of plant operations was interviewed on 1/13/10 at 2:00 p.m. and stated dietary staff was responsible to clean the microwave ovens daily. The chief operating officer viewed the microwave ovens and the toaster on 1/14/10, at 10:45 a.m. and agreed they were not clean.

Based upon interview and review of the organizational chart, the hospital did not ensure the director of Rehabilitation Services had the necessary qualifications to supervise and administer Rehabilitation Services within the hospital. Findings include:

A review of the organizational chart provided by the facility indicated the director of clinical services was the director of the rehabilitation service program.

The director of clinical services (DCS) and an occupational therapist-A (OT-A) were interviewed on 1/12/10 at 1:20 p.m. The DCS stated she was a registered nurse, and the director of the hospital's rehabilitation program. The OT-A explained she was considered the team lead in the rehabilitation program. She also served as a liaison between the therapists and the DCS, since the DCS was not a therapist. The DCS stated she was responsible for hiring, evaluating performance, and disciplining rehabilitation department employees. She stated she had administrative accountability for the rehabilitation department.
The OT-A stated the rehabilitation department consisted of two full time physical therapists, two physical therapy assistants, two occupational therapists, two occupational therapy assistants, as well as one full time and two part time speech-language pathologists (SLPs).

The OT-A provided input for performance appraisals for the OT and the OT and PT assistants. She stated she did not provide any input into the performance evaluation of the SLPs or the physical therapist.

The DCS stated she was not a physical or occupational therapist nor a speech-language pathologist. She stated the OT-A did not have administrative responsibility for the rehabilitation department.